=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750431847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAYLOR MEDICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 09/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2315 E 93RD ST STE 240
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-375-8366
-----------------------------------------------------
Fax | 773-375-8319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2315 E 93RD ST STE 240
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-375-8366
-----------------------------------------------------
Fax | 773-375-8319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | JULIE V TAYLOR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-375-8366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036085106
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------